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An Exploration of Discharge Summaries of Psychiatric Patients
Anil Kumar Deo
A dissertation submitted to the University of Dublin in partial fulfilment of
requirements for the Master of Science in Health Informatics degree
2016
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Declaration
I declare that the work in this dissertation is, where otherwise stated, is entirely my own
work, and has not been submitted as an exercise for a degree at this or any other university.
Signed:
Anil Kumar Deo
Date:
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Permission to Lend or Copy
I agree that the Trinity College Library may lend or copy this dissertation upon request.
Signed:
Anil Kumar Deo
Date:
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Dedication
This work is dedicated to
Sunil Kumar Deo and Mrs Kalpana Poddar,
my Parents
“Success is not final,
Failure is not fatal: it is the courage to continue that counts.”
Winston Churchill
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Acknowledgement
I am very grateful to Goddess Saraswati for her numerous blessings bestowed on me
throughout the course of my dissertation. I wish my gratitude and honest thanks to Professor
Gaye Stephens, my research supervisor, for her patience, support, guidance, expertise and
encouragement. I am obliged to her for her understanding, perception, and critique of my
dissertation.
I wish to convey my thanks to Dr Lucy Hederman, course director, for her insightful support
and guidance throughout.
I am very thankful to Dr Eugene Breen, Consultant Psychiatrist, Mater Misericordiae
University Hospital (MMUH), Dublin.
I would like to thank those at MMUH who gave me permission to conduct my study.
I also wish to thank all research participants for this study from the Dublin 7 area for their
support without which this study would not have been possible.
I thank my parents for their continuing support. I dedicate my work to my parents who gave
me emotional support.
A special note of thanks goes to my wife, Sanober Francis, and my son, Sanjit Kumar Deo,
for their emotional support and understanding during stressful times.
At last, I would like to convey my loving gratitude and thanks to everyone who directly and
indirectly supported me throughout this study.
Anil Kumar Deo
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Abstract
The discharge summary is an important document of communication between the hospital
and community team. In 2013, HIQA (Health Information and Quality Authority) developed
the “National standard for patient discharge summary information” which highlighted the
standard for general discharge summaries. However, there is evidence that a gap of
communication between the hospital and primary care team still exists in specialities like
psychiatric care. The aim of this study is to develop the minimum dataset for psychiatric
discharge summaries. Poor information content of psychiatric discharge summaries and the
requirements of the primary healthcare team led the researcher to conduct this study to
identify the contents need of GPs.
This study was conducted in a Dublin hospital and with a survey of Dublin based GPs
(General Practitioners). A mixed design was used to develop the minimum data set for
psychiatric discharge summaries. One hundred random reviewing charts were selected from
the total discharge summaries of the Mater psychiatric ward for 2015. Then a survey was
done of 50 GPs selected from the GP list on the HSE (Health and Safety Authority) website.
Data was collected through a structured questionnaire of these GPs. The researcher only
received 12 completed questionnaires. Data set definitions were identified from HIQA
guidelines and literature.
The analysis of discharge summaries identified a significant gap of communication between
the hospital and primary care team. Important contents were missing from the discharge
summary such as the patient’s address, nationality, next of kin, GP details, admission, and
source of admission, address the patient is discharged to, clinical information such as mental
state examination (MSE) at discharge, past psychiatric history, social history and risk factor.
A survey of GPs suggested that there is a gap between GPs’ expectations and current
discharge summary contents. GPs expect full details of discharge summaries matching the
National Standard on Information of Discharge Summary (HIQA 2013).
This researcher suggests improvement of the minimum data set for psychiatric discharge
summaries. The researcher also suggests conducting the same study on larger sample size to
increase generalisation.
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Table of Contents
Declaration ii
Permission to lend and/or copy iii
Acknowledgement v
Abstract vi
Table of Contents vii
Appendices x
List of Figures xi
List of Tables xii
Abbreviations xiii
Glossary of Terms xiv
Chapter 1 Introduction 1
1.1 Background 1
1.2 Study Significance 2
1.3 Rationale for the Study 3
1.4 Research Objectives 4
1.5 Research Question 4
1.6 Outline of Research Dissertation 4
1.7 Summary 5
Chapter 2 Literature Review 6
2.1 Introduction 6
2.2 Psychiatric Discharge Summary & the Minimum Data Set: Definitions 6
2.3 Psychiatric Care in Ireland 7
2.4 Difference between Generic & Psychiatric Discharge Summaries 9
2.5 Contents of Discharge Summaries 9
2.6 Discharge Summary Guidelines in Ireland 10
2.7 Legal Requirement for Data Management in Ireland 11
2.8 Implications of the Discharge Summary 11
2.9 Challenges of the Discharge Summary 12
2.10 European and International Initiative Related to the Discharge Summary 13
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2.11 Electronic Discharge Summary 17
2.12 Minimum Data Set 18
2.13 Benefits of Minimum Data Sets for the Discharge Summary 18
2.13.1 Benefits for Patients 19
2.13.2 Benefits for the Primary Care Team 19
2.13.3 Benefits for Hospitals 19
2.13.4 Other Benefits 19
2.14 Principle of Developing a Minimum Data Set 19
2.15 Development Process of the Minimum Data Set 20
2.16 Privacy, Confidentiality, Security, and Encryption 23
2.16.1 Encryption 24
2.17 SNOMED-CT 24
2.18 Findings from Literature Review 24
2.19 Summary 25
Chapter 3 Research Design & Methodology 27
3.1 Introduction 27
3.2 Research Approach & Design 27
3.3 Research Methodology 28
3.4 Research Design 29
3.4.1 Context of Use 30
3.4.1.1 Systematic Review 30
3.4.2 User Requirement Specification 31
3.4.3 Template Development & Evaluation 31
3.5 Tool Development Process 31
3.6 Questionnaire 32
3.7 Data Collection Tool 32
3.8 Participant Recruitment Method 32
3.8.1 Inclusion Criteria 33
3.8.2 Exclusion Criteria 33
3.9 Validation 33
3.10 Ethical Approval 33
3.11 Data Analysis 34
3.12 Summary 34
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Chapter 4 Results, Analysis & Discussion 35
4.1 Introduction 35
4.2 Contents of Discharge Summary 35
4.2.1 Patient Details 35
4.2.2 Primary Healthcare Professional Details 36
4.2.3 Admission & Discharge Details 37
4.2.4 Clinical Information 37
4.2.5 Future Management 38
4.2.6 The Details of the Person Completing the Discharge Summary 39
4.2.7 Review of Discharge Summary in Study Hospital 40
4.3 GPs’ Opinions on Discharge Summary 42
4.3.1 GPs’ Opinions on Demographic Details 42
4.3.2 GPs’ Opinions on Primary Healthcare Professional Details 44
4.3.3 GPs’ Opinions on Admission & Discharge Details 45
4.3.4 GPs’ Opinions on Clinical Information 46
4.4 Minimum Data Set for the Psychiatric Discharge Summary 47
4.5 Summary 54
Chapter 5 Conclusion & Future Work 55
5.1 Introduction 55
5.2 Key Findings 55
5.3 Achievement of Objective and Research Question 55
5.4 Recommendations for Future Work 56
5.5 Limitation of the Study 56
Chapter 6 Summary 57
References 59
Appendices 69
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Appendices
Appendix 1 Research Ethical Committee Approval Letter, TCD
Appendix 2 Research Ethical Committee Approval Letter, MMUH
Appendix 3 Research Ethical Committee Application Cover Letter, MMUH
Appendix 4a Permission letter from Consultant Psychiatrist, MMUH
Appendix 4b Permission Letter to Consultant Psychiatrist
Appendix 4c Permission letter from Consultant Psychiatrist
Appendix 5 Participant’s Consent Form
Appendix 6 Participant’s Information Leaflet
Appendix 7 Cover letter for General Practitioners
Appendix 8 Survey Questionnaire
Appendix 9 Data Collection Tool for Reviewing Chart
Appendix 10 Contents of Discharge Summary by HIQA (2013)
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List of Figures
Figure 2.1 Discharge process and factors that lead to rehospitalisation and/or complication
Figure 2.2 Development Process of minimum data set
Figure 3.1 Conceptual Framework for Research Design
Figure 3.2. Schematic of User’s Requirement Process
Figure 3.3 Research Review Process
Figure 4.1 Frequency of Contents of Patient Details in the Discharge Summary
Figure 4.2 Frequency of Primary Healthcare Professional’s Details
Figure 4.3 Frequency of Admission and Discharge Details
Figure 4.4 Frequency of Clinical Information Details
Figure 4.5 Frequency of Future Management Details
Figure 4.6 Frequency of Person Completing Discharge Summary Details
Figure 4.7a Frequency of GPs’ Opinions on Demographic Details
Figure 4.7b Frequency of GPs’ Opinions on Demographic Details
Figure 4.8a Frequency of GPs’ Opinions on Primary Healthcare Professional Details
Figure 4.8b Frequency of GPs’ Opinions on Primary Healthcare Professional Details
Figure 4.9a Frequency of GPs’ Opinions on Admission & Discharge Details
Figure 4.9b Frequency of GPs’ Opinions on Admission & Discharge Details
Figure 4.10a Frequency of GPs’ Opinions on Clinical Information
Figure 4.10b Frequency of GPs’ Opinions on Clinical Information
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List of Tables
Table 2.1 Key Parameters in Irish Mental Health Services 1984 and 2004
Table 2.2 List of Contents Omitted or can be Omitted
Table 2.3 Contents Deficits when Transferring Information
Table 4.1 Omitted Contents of Discharge Summary
Table 4.2 Minimum Data Set for Demographic Details
Table 4.3 Minimum Data Set for Primary Healthcare Professional Details
Table 4.4 Minimum Data Set for Admission and Discharge Details
Table 4.5 Minimum Data Set for Clinical Information
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Abbreviations
ACSQHC Australian Commission on Safety & Quality in Health Care
AIHW Australian Institute of Health & Welfare
CCTP Community-based Care Transition Programme
CIA Central Intelligence Agency
DOB Date of Birth
DS Discharge Summary
EDS Electronic Discharge Summary
epSOS European Patient Smart Open Service
GP General Practitioner
HIPE Hospital In-Patient Enquiry
HIQA Health Information & Quality Authority
HIT Hospital Information Technology
HSE Health Service Executive
ICD International Classification of Disease
ICS Irish Coding System
ICT Information & Communication Technology
ID Identification
IEEE Institute of Electrical and Electronics Engineers
IOM Institute of Medicine
ISF Integrated Services Framework
LIS Laboratory Information System
MSE Mental State Examination
MDS Minimum Data Set
NEHTA National E-Health Transition Authority
NHS National Health Service
NICE National Institute for Health Care & Excellence
NPSA National Patient Safety Agency
NSA National Security Agency
PAS Patient Administrative System
RCOPI Royal College of Physicians of Ireland
SNOMED-CT Systematized Nomenclature of Medicine-Clinical Terms
UKCC United Kingdom Central Council for Nursing and Midwifery
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Glossary of Terms
Confidentiality The statutorily protected right and duty of health professionals
not to disclose information acquired during consultation with a
patient (Craig et al 2007).
Data Data is raw unorganised facts that need to be processed or
organised. It can be numbers, symbols, words, images and
graphics that have to be analysed (AIHW 2007).
Discharge Summary Discharge summary is “information required in a generic
clinical discharge summary produced at the time of discharge
from secondary or tertiary care” (HIQA 2013).
Electronic Health Record A longitudinal electronic record of patient’s health information
across multiple care settings. It contains multiple EMR
(Electronic Medical Record) and EPR (Electronic patient
record) which is shared across settings (HIQA 2013).
Encrypting Encryption is the conversion of electronic data into another
form, called cipher text, which cannot be easily understood by
anyone except authorized parties (Fernandez-Aleman 2013).
HIQA HIQA is an independent authority formed by the government
and is responsible for maintaining quality, safety and
accountability in health and social care services in Ireland.
They develop the standard, inspect the health service, monitor
the compliance with standard, publish the health care delivery
performance statistics, and perform investigations (HIQA
2013).
ICD The International Classification of Diseases (ICD) is the
standard diagnostic tool for epidemiology, health management,
and clinical purposes (WHO 2015).
Minimum data set The minimum data set (MDS) is a set of nationally agreed data
items that are collected in relation to clients, the services they
receive, and the outlets that provide these services (ADHC
2015).
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Mixed method Mixed method is a combination of qualitative and quantitative
research methodologies (Burns & Grove 2005).
SNOMED-CT SNOMED-CT is a standardised, multilingual vocabulary of
terms relating to the care of the individual. It enables the
representation of care information consistently, reliably and
comprehensively as an integral part of the electronic care
record (International Health Terminology Standards
Development Organisation 2013).
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Chapter 1
Introduction
1.1 Background
It is estimated that one out of four people will experience mental health problems in their
lifetime. These can range from minor to severe depression, with a small number of people
experiencing severe mental health issues. Most people with mental illness can be treated by
their GP or can be referred to a psychiatric service (Health Research Board 2011).
There are various categories of mental health service in Ireland which have seen dramatic
changes in development over the past 20 years. These changes contributed to the movement
of services from hospitals to the community and in the patient’s own home (HIQA 2013).
In Ireland in 2010, 19,614 patients were discharged from psychiatric hospitals. Almost half of
the discharges occurred within two weeks of admission, whereas 26% took place within a
month and 90% occurred within three months of admission. The average length of stay for
admissions is 26 days (Health Research Board 2011).
Sharing information should be accurate, valid, timely, relevant, and legible. When
information sharing is needed then patients’ privacy and confidentiality should be respected.
Improperly shared information leads to risking both the safety and quality of care. (HIQA
2013).
Hospital discharge summaries are basic documents for sharing information between primary
and secondary care providers. A discharge summary is the form which will go with the
patient to their primary care team. The psychiatric discharge letter has two main purposes:
one is internal, that is, for future reference in continuity of care in a secondary care setting,
and the second is to communicate with primary care (Kripanali et al 2007; Val Walraven et al
1995).
The discharge process is the transfer of information from secondary care to primary care, and
a discharge summary is needed to transfer the information. It can be in any form, such as a
letter (hand written or typed) but in some cases it can be produced electronically (CIHI 2009;
Kripanali et al 2007).
Mentally-ill patients are more vulnerable than other patients discharged from hospital. The
first two weeks after discharge are the most critical time. This is the time when problems
arise and more support is needed; drugs run out, and default from follow-up is most likely
(Kripanali et al 2007).An effective discharge summary could assist in providing continuity of
care during this vulnerable period. Not all acute psychiatric units send timely discharge
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summary. There is always a delay in sending summary sheets from primary care settings.
Even when this is done, there is little agreement about what information is of most value to
the GP. Previous studies have shown that vital information about management, follow-up
plans and responsibilities is often omitted. Junior hospital staff are rarely taught how to write
discharge summaries that are relevant to GP’s needs. Another important factor is that few
psychiatric discharge summaries are designed to meet the specific information needs of those
responsible for follow-up care in the community (Val Walraven et al 1995; Olfson et al
1997).
The aim of this dissertation is to review the information needs of primary care health
professionals in relation to the discharge of mentally ill patients. From this study, the
researcher aims to produce an appropriate psychiatric discharge summary that meets the
needs of health care professionals and mentally-ill patients. In this study the researcher will
also investigate the current contents of discharge summaries in order to develop templates for
an electronic version of the discharge summary.
1.2 Study Significance
Hospital discharge summaries act as basic documents for sharing information about patient
care plans to the primary care team (CIHI 2009; Kripanali et al 2007). The discharge
summary is also shared with follow-up teams in the community (CIHI 2009). High quality
discharge summaries are needed to preserve patient safety during transfer of care from
tertiary care to the community team (CIHI 2009; Val Walraven et al 1995, 1999, 2002).
Poor care is associated with a shortcoming of shared information between the tertiary care
and primary care team. In 2008, the UK National Prescribing Centre (NPC) published a
guideline about the minimum data set to be communicated between the hospital and any other
agency upon discharge (Coleman EA, 2003). The NPC recommended eleven headings as the
minimum data set for the discharge summary such as patient details, diagnosis in current
condition, procedure carried out, medication details, medication dose and route, medicine
start and stopped with reason, details of dose lowering and increasing details, drug allergy
details, anticoagulant details log book, and deadlines for sending discharge summary to GP.
Patient safety depends on the communication of clinical information within health care
settings. Despite NPC (2008) guidelines on discharge summaries, there is plenty of evidence
to show that omissions of content from the discharge summaries are frequent. The content of
the discharge summary can be improved by using the electronic discharge templates (Eman et
al 2014).
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There is evidence of quality discharge summary content compromise due to delay, content
omissions and formatting but the completion rate of the discharge summaries are good.
Digital research is available in rich datasets contained in GP records to find out the discharge
summary receipt rate and timing (Belleli et al 2013).
The HSE conducted an e-Health consultation process between December 2011 and January
2012 which highlighted an area of priority for the improvement of standards. E-prescription
was reviewed by the Health Information Directorate and the results suggested the
development of a plan of action for the newly structured e-Health Standards Advisory Group
(eSAG). The action plan was agreed with eSAG and this provided the basis for the
development of a minimum dataset for clinical discharge summaries and complements the
National Standard for Patient Referral Information previously developed by HIQA (HIQA
2011).
In 2013, HIQA drafted the National Standard of Patient Discharge Summary Information
and submitted it to Dr James Reilly, Minister of Health, for approval. This draft contains
seven headings to be included in the discharge summary which are: patient details, primary
healthcare professional details, admission and discharge information, clinical information,
medication information, follow-up and future management, and details of the person
completing discharge summary (HIQA 2013).
Mentally-ill patients are the most vulnerable group amongst discharged patients. The first two
weeks after discharge are critical to mentally-ill patients as this is when problems arise such
as drugs running out and defaulting from follow-up care (Abbas et al 2015).
1.3 Rationale for the Study
Routinely, the printed discharge summary, which is generated by computer, is posted to GPs
as part of the discharge process. However, GPs and clinic staff always need to call the
secondary care centre for further information about follow-up care. This indicates that the
current discharge summary is lacking the appropriate information for continuity of care at
primary care level and furthermore suggests that there is a gap in sharing information
between hospital and GPs. Modern clinical practice seeks to minimise hospitalization and
decrease the number of readmissions. The researcher reviewed studies which revealed similar
problems and this suggests the need for standardised discharge summaries across the hospital
especially for the psychiatric service.
HIQA (2013) published the National Standard of Patient Discharge Summary Information
which highlights the contents to be included in the discharge summary yet there is still a need
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to improve the implementation of national standardised discharge summaries in hospitals.
This study will find out how far hospital discharge summaries comply with the HIQA
guidelines outlined in this publication.
1.4 Research Objectives
Research objectives are:
1. To determine compliance in the discharge summary with HIQA guidelines for its
content.
2. To identify omitted contents.
3. To develop a minimal data set for contents of discharge summaries.
4. To develop a template for an electronic version of the discharge summary.
1.5. Research Questions
The aim of this dissertation is to identify to what extent is the study hospital’s discharge
summary complying with HIQA guidelines and to develop the ideal discharge summary.
The researcher aims to answer the following research questions:
1. What proportions of discharge summaries at the Department of Psychiatry conform to
the standard guidelines?
2. To what extent are contents of the discharge summary omitted?
3. What do primary care health professionals need in a discharge summary?
4. Design a paper discharge summary form.
1.6. Outline of Research Dissertation
Chapter 1 This chapter discuss the background and significance of this study, the
rationale for the research, the research objectives and questions, and an outline
of dissertation.
Chapter 2 Discusses the literature review to provide background information on
discharge summaries and its role in psychiatric care in Ireland. It also
elaborates on how generic and psychiatric discharge summary are different.
The development of the minimum data set is also discussed.
Chapter 3 Identifies the research design and methodology for research, tool
development, participant recruitment methods, data collection process, ethical
approach, and analysis plan.
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Chapter 4 Presents the results and an analysis of the research findings, analysis and
finding of chart reviews and GP survey. This chapter also includes graphical
presentation of results.
Chapter 5 Presents key findings, achievement of study objectives, recommendations for
future work and limitations of the study.
Chapter 6 Presents the summary of research study.
1.7 Summary
There is a problem in sharing information between hospitals and primary care teams and this
interferes with continuity of care. Although the National Standard of Patient Discharge
Summary Information may appear to manage the problems, there is need for a separate
standard minimum data set for the psychiatric discharge summary.
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Chapter 2
Literature Review
2.1 Introduction
The developments of discharge summaries during the past 17 years have indicated an
improvement in quality. There were various measure introduced to improve the quality.
(Maserat 2008). There has been a recent move in psychiatry to introduce an electronic
discharge summary to improve communication between the hospital and the primary care
team (Abbas et al 2015).
Mental Health Commission (2007) recommends that there is an expectation that mental
health service is delivered with full participation of patient acknowledging the role of primary
care team in clinical care, informational, and educational support of family. The number of
readmission of psychiatric patient is high in Ireland. Readmission is occurred due to lack of
proper sharing of information between hospital and primary care team.
In this chapter in-depth literature review is discussed. Literature review is carried out from
1999 to 2016. In literature search, discharge summary, psychiatric discharge summary,
minimum data set were used as term for searching. Qualitative, quantitative and mixed all
type of studies were included in literature review. This section includes psychiatric care in
Ireland, psychiatric discharge summary, minimum data set development process, EU &
International view on discharge summary and its privacy.
2.2 Psychiatry Discharge Summary and the Minimum Data Set; Definitions
The National Standard for Discharge Summary defines a discharge summary as the
“information required in a generic clinical discharge summary produced at the time of
discharge from secondary care or tertiary care.” (HIQA 2013, p.9)
A discharge summary is a “collection of information about events during care by a provider
or organisation.” (AS4700.6 (Int) 2007)
Psychiatric care refers to care given to mentally-ill patients throughout the illness until
recovery (Nice 2014).
Psychiatric discharge summaries are the communication tool between the hospital and
primary care team. Discharge summaries facilitate information sharing for continuity of care
of mentally-ill patients.
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A data set is a set of information which is gathered for certain reasons. The minimum data set
(MDS) is a set of nationally agreed data items that are collected in relation to clients, the
services they receive, and the outlets that provide these services (ADHC, 2015).
2.3 Psychiatric care in Ireland
The history of Irish mental health services is well-documented. Mental health service was
hospital based and there were demands for hospital beds for psychiatric illness (Finanne
1988; Robins 1986; Reynolds 1992; Walsh & Daly 2005). Reports from the Commission of
Inquiry on Mental Illness and Planning for the Future suggested some recommendations for
the improvement of mental health care especially a reduction in in-patient care (Department
of Health, 1966; 1986). Most of the mental health service is carried out in the community; the
majority of patients are seen at outpatient settings such as day hospitals, day centres and in
the home. Only a minority of patients are admitted to hospital. Unfortunately, the figures
show that we have more information about in-patient mental health services than community
services. Patients were unaware of information about in-patient services related to
intervention and the treatment they were receiving. Though, there is some information
available about the mental health service in Ireland as can be seen in Table 2.1, there is also a
lack of information on the number of people with mental health problems in the Irish
population.
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Table 2.1 Key parameters in Irish Mental Health Services: 1984 & 2004
Source: A Vision for Change: Report of the Expert Group on Mental Health Policy, 2006 (The
Stationery Office of Dublin, 2006)
Mental health services are governed by legislation and policy. The Irish mental health service
is regulated by the Mental Treatment Act 1945 which was then extended to 1970. A third act
followed namely the Mental Health Act 2001 which provides a basis for the formation of the
Mental Health Commission (MHC). This is an independent statuary body which is
empowered by the Mental Health Act 2001. The MHC will foster and promote high standards
in the delivering of mental health services and ensuring the rights of detained patients are
taken care of.
The central recommendation of the planning for the future model focused on a
multidisciplinary approach to effectively co-ordinate continuity of care. This model of care
emphasises community-based care extending to the individual home. When patients are
discharged from hospital, they are referred to a GP for follow-up care (Vision for Change
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2006). A clinical discharge summary is generated after the patient’s stay. This provides a
basis for communication between health care professionals from the hospital to the primary
care team. An incomplete and delayed clinical discharge summary puts the patient at risk and
reduces the quality of aftercare (HIQA 2013).
2.4 Difference between Generic & Psychiatric Discharge Summaries
The standard discharge summary contains demographic details, primary health care
professional’s details, admission discharge details, the clinical narrative, medications, and
follow-ups. The NHS has published guidelines about the contents of psychiatric discharge
summaries. It contains demographic details, the name of the consultant, GP details, admission
and discharge details, legal status, reason for admission, history of present illness, past
medical history, past psychiatric history, family history, social history, occupational history,
pre-morbid personality, mental state examination, physical examination, results of
investigations, progress and treatment during admission, final diagnosis, discharge
medication, follow-up arrangement, name of key workers, and number of pages.
The studies on discharge summaries relating to communication from secondary to primary
care showed the importance of accuracy and quality of information (Kazmi 2008), errors
(Crosson et al 2004) and GP preference (Serfontein et al 2011). Review studies found that
there was little availability of discharge summaries during the first visit to the primary care
team after discharge. There were wide differences in the contents of discharge summaries
which directly affected patient care (Kripalani et al 2007; Knai et al 2013). Various details
were absent from the discharge summary such as details on medication, follow-up care,
mental state examination and the physical examination carried out during the patient’s stay.
These details are an important part of follow-up care for the primary care team and transition
of care from hospital to the community (Shashtri et al 2014).
2.5 Contents of the Discharge Summary
Hospital discharge summaries act as important tools for sharing information to the
community care team. Discharge summaries are often used as a form of communication to
the next care setting (Kripalani et al 2007; Van Walraven 1995). The Joint Commission
International (JCI) is an organisation which measures and share best practices in quality and
patient safety worldwide. The JCI highlighted six components in the discharge summary: the
reason for hospitalization, significant findings, procedures and treatment provided, patient’s
discharge condition, patient and family instructions (as appropriate), and attending
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physician’s signature (Joint Commission USA 2008). However, there no clear and specific
definition exists in report of JCI. The contents of discharge summaries approved by the
NEHTA include diagnosis, diagnostic procedures performed, the prognosis, medications
prescribed and follow-up actions recommended (NEHTA 2014). There are various view
points on the important components of the discharge summary. Studies conducted by Carey
and Hall (1999), Archbold et al (1998), and Crosswhite et al (1997) highlight admission and
discharge details, diagnosis, advice to the patient, details of medication, investigation details,
and follow-up as the important components of a discharge summary. Solomon et al (1995)
identifies diagnosis, drugs at discharge, investigations and follow-up as the important
components of discharge summaries. However, according to Kripanali et al (2007) and
O’Leary (2006) the main components of the discharge summary are diagnosis, physical
examination, past medical history, in-patient treatment, procedure results, laboratory results,
any recommendation by consultant, advice to patient and family, condition at discharge,
details of medication and any changes, indication for newly prescribed medication and
follow-up.
HIQA (2013) guidelines on the National Standard on Discharge Summary have similar
components which other agencies and studies mentioned. Appendix 10 describes about the
contents of discharge summaries suggested by HIQA (2013).A survey by Walvaren and
Rokesh (1999) on hospital and community care physicians suggested that high quality
discharge summaries should be short, contains appropriate information, and should be
delivered quickly.
2.6 Discharge Summary Guidelines in Ireland
In Ireland, HIQA is the independent body who maintains high standards in relation to health
and personal care. Under section (8)(1)(K) of the Health Act 2007, HIQA has responsibility
in establishing standards and maintaining that standard of care. The main standards on the
discharge summary are outlined in HIQA’s 2013 publication, National Standard for Patient
Discharge Summary Information.
Other national guidelines related to discharge summaries are:
Guiding Principle for National Health and Social Care Data Collection (HIQA
2013),
National Standard Demographic Data Set and Guidance for use in Health and Social
Care Settings in Ireland Version 1.0 (HIQA 2013),
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Recommendation Regarding the Adoption of SNOWMED Clinical Terminology for
Ireland (HIQA 2014),
What You Should Know About Data Quality: A guide for health and social care staff
(HIQA 2012).
In 2015, the Chief Information Officer, Richard Corbridge, published the document,
Knowledge and Information Strategy: Delivering the Benefits of eHealth in Ireland, which
focuses on the need for standard requirements in electronic patient records and integrating
different organisation records at a national level. The three documents are:
HSE Design Authority (2015) – ISF program ICT Asset base work stream 2.2 -
Application and Technological “T Be” Logical Architecture,
HSE design authority (2015) – ISF program ICT Asset base work stream 2.4 -
Standard Catalogue,
HSE Design Authority (2015) – ISF program ICT Asset base work stream 2.4 -
Classification Asset Model.
2.7 Legal Requirements for Data Management in Ireland
HIQA (2013) suggests that each organisation should ensure that standardised procedures are
in place for data collection. The legislation which is in place for discharge summary are:
Data Protection (Access Modification)(Health) Regulation 1989,
Data Protection Act 1988, Data Protection Act Amendment 2003 and subsequent
legislation,
European Statistics Code of Practice (2011),
Freedom of Information Act 1997, 2003 and subsequent regulation,
Health (Provision of Information) Act 1997,
Health Act 2007,
Health Information Bill 2014,
2.8 Implications of the Discharge Summary
Discharge summaries are a vital document which gives full information about in-patient
staying, patient’s details, admission and discharge details, treatment plan and follow-up care.
Discharge summaries can be used for retrospective and epidemiological study and research.
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High quality discharge summaries provide assurances regarding patient safety by sharing
important pieces of information among health care settings (Yemm et al 2014).
2.9 Challenges of the Discharge Summary
There are many studies which show that there is poor communication between hospital and
community care (Tulloch et al 1972; Roy et al 2005). Family physicians prefer a high quality
discharge summary (Van Walraven & Rokosh 1999). There are a number of studies which
suggest ideas to improve the content’s quality.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) conducted a
study and found the pertinent challenges of discharge summaries are a delay in
communication, inclusion of inaccurate and unnecessary information, and omission of
important contents (ACSQHC 2010). A study by Moore et al (2007) reported that one third of
all post-discharge workup procedures were incomplete.
Kripalani et al (2007) identified that availability of the discharge summary for GP visits
during the first two weeks were very low, that is 12–20%. Similar findings are reported by
Moore et al (2003) where they discovered that a significant number of patients had medical
errors due to failure to communicate between two providers of care. The risk of readmission
was increased by 50% or more due to delayed discharge (Van Walraven et al 2002; Li JYZ et
al 2013). Lack of proper communication and inadequate information transfer during
discharge is the main cause of errors and near misses (Forster et al 2004, 2003; Kripalani et al
2007). O’Leary et al (2006) reported that 41% of general interns felt one patient in six
months had a preventable reaction due to inadequate transfer of information.
Were et al (2009) reported that only 16% of the pending tests at discharge were reported in
the discharge summary whereas only 67% of discharge summaries can be identified by an
outpatient provider to whom lab results could be sent. Walz et al (2011) found that one third
of discharge patients had pending test results but only one third of the pending test results
were mentioned on the discharge summary. A study by Roy et al (2005) found that 41% of
test results were pending and 61.6% of primary care providers have no knowledge of
outstanding results.
A study by McMillan et al (2006) found that 222 medication errors occurred in 100 discharge
summaries. Out of 222 medication errors, 13% of errors were harmful and that could lead to
readmissions. Another study by Perren et al (2008) on 622 discharge summaries discovered
an omission of medication on 40% of the discharge summaries, of which 35% of patients
were in a harmful situation. NICE (2008) reported that there were errors, 30–70%, of
13
unintentional changes to medication when the patient was discharged from one care to
another care facility. The risk of readmission is increased due to lack of care, monitoring and
treatment by the GP as there is always delayed communication through the discharge
summary. (Walraven et al 2002). Uncoordinated and inadequate contents in the discharge
summary were reported by Russell et al (2013). Other problems associated with discharge
summaries are an increased death rate (O’Brien 2006), increased physical illness (Wong et al
2008; Scott 2010), adverse incidents such as fall, infection and medication errors (Bywood et
al 2011), delay in medication dispensing (McDonald 2007; Elliot et al 2012), additional
phone call and visit to emergency and primary care (McDonald 2007; Wong 2008), and risk
of repeat test (Wong 2008: Global et al 2012). There is no study that researches the increased
cost due to issues with the discharge summary (Rigby et al 2012; Richardson & McKie
2007). Few studies were conducted on the pain and emotional suffering of the family due to
improper discharge information between primary care and secondary care (Wong 2008;
Bywood et al 2011). Eighteen percent of patients felt that this is a waste of time because their
care is disorganised during discharge process (Wong et al 2008; Schoen et al 2008).
There are few studies which show that there are no proper standard guidelines for evaluating
a good quality discharge summary. Therefore, different methods need to be adopted to
evaluate the discharge summary. There is a lack of uniformity about the completeness of the
discharge summary because different doctors complete the discharge summaries differently.
To overcome this problem, Stainkey et al (2010) suggests the need of a minimum data set. A
study by Lauden (2009) suggests that summaries contain inadequate and unimportant
information and fail to reach discharge summary to GPs on time. It can be concluded that
there is problem with the delay in delivering the discharge summary to the GP, and a lack of
appropriate information and omissions are the main reasons for poor quality discharge
summaries.
2.10 European & International Initiatives Related to the Discharge Summary
There are many initiatives done throughout the world to overcome problems with discharge
summaries. In the UK, the Royal College of Physicians (RCP) started a project on how to
improve clinical handover and developed a standardised format for medication information,
discharge summary templates and a safe system to transfer information. This important
information generated by the RCP and the Royal Pharmaceutical Society for the NHS in 2012
(Russell et al 2013).
14
A safety program started in Scotland, in conjunction with GP surgeries, to find out the key
areas of transferring the patients within the health care organisation. These initiatives sorted
mainly the medication reconciliation and communication between the GP surgery and
hospital outpatients. This process of safeguards guarantees that discharge summaries are in
use on the day of receiving and medication reconciliation is applied on the second day. It is
also ensured that any changes in medication are discussed with patients and their relatives
(Health Improvement Scotland 2011).
In Australia, the ACSQHC (2009) suggested a standard which ensures timely, relevant, and
clinical handover. The ACSQHC developed the guideline OSSIE, an electronic resource for
clinical handover and electronic discharge summaries. The Australian Government and its
state territories launched the program which focused on improving communication between
primary care and hospital. The New South Wales (NSW) programme showed the best
practice of sharing information between hospital and primary care (Russell 2013). The NSW
program provides support in technology development for E-health, advanced manufacturing,
energy technology, online interactive education, transport, logistic and infrastructure.
In the US, a number of projects such as Re-Engineered Discharge (RED), Better Outcomes
for Older Adults through Safe Transitions (BOOST), Partnership for Patients Safety
Campaign (PfP), and community-based Care Transitions Program, were implemented to
improve communication between hospital and community care. These projects were
implemented after a report by the Institute of Management was published in 2009. In
Colorado, the number of readmissions was reduced by 30 % after implementation of a RED
project programme and cost was reduced by 20 % (Coleman et al 2007). In 2011, the
community-based care transition program (CCTP) was launched to improve sharing of
information from hospital to community. The 2013 annual report showed that there was a
reduction of readmission but it was hard to generalise because it was too early to evaluate the
programme (CCTP 2014).
A study on discharge summaries by Glonti et al (2013) found that there was no standard or
guideline on discharge summaries in the EU. Poland and Lithuania proposed a national
guideline on standard discharge summaries. Spain and Scotland proposed a minimum data set
whereas Denmark proposed electronic standard discharge summaries. In England, Standard
structure and contents headings were suggested. France and Finland initiated standard
discharge summaries proposed by hospital accreditation bodies (Glonti et al 2013). This same
study also revealed that there were extensive differences in the quality of discharge
15
summaries. Lack of information, missing contents and a lack of ICD classification were key
issues with discharge summaries in the EU.
European hospital discharge summaries contain inadequate information for follow-up care.
The guidance for discharge summaries is available in seven EU member states. There were
wide variations in the contents of discharge summaries among EU countries. In the EU, there
are core components to the discharge summary but in there is wide variation in the total
contents of discharge summaries among member states hospitals alone, not to mention the
entire EU. A study by Glonti et al (2013) revealed that there is a need for a common
minimum data set for better quality discharge summaries. Cross Border Health Care in
Europe (Footman et al 2014) suggests that follow-up care is the weakest point in discharge
summaries within cross border care. The European Patients - Smart Open Services (epSOS)
developed a minimum data set for discharge summaries applicable to the EU. Table 2.2
shows the omitted contents in discharge summaries.
16
Table 2.2 List of Contents Omitted or can be Omitted
Source: e-Health Network 2013
The European Union launched a project called “Trillium” which aims to deliver transatlantic
exchange of patient information. In the US, there was programme launched which allows
patients to download their medical records. A study by Esteilrich et al (2014) which
compared discharge summaries from the EU with US continuity care documents, found that
there was a similarity in the standard of format but variations in the terminology used which
made exchange of information difficult.
17
Table 2.3 Contents Deficits when Transferring Information
Source: Kripalani et al (2007) JAMA, 8, p.836
Figure 2.1 Discharge process and factors that lead to rehospitalisation and/or complications
Source: Jeffrey et al (2003). Patient Saf Volume 3, Number 2:97-106.
2.11 Electronic Discharge Summary
Traditionally, discharge summaries are handwritten or computerised. Over time, discharge
summaries have improved as a standard format was introduced. To improve the quality of
18
discharge summaries, computerised versions are introduced. Presently, the advancement of
information technology encourages the use of electronic discharge summaries.
The electronic discharge summary (EDS) is a perfect document in the context of
comprehensiveness, clarity, time and relevant information for the continuity of care (Reinki
et al 2014). Regarding the timely sharing of information, the EDS is well prepared on the day
on or before the discharge date. A further advantage of EDS is the easy ability to change and
update from resources. However, Callen et al (2010) evaluated the documentation of EDS.
This study found that it is debatable whether the quality of the EDS is better in comparison to
handwritten summaries.
2.12 Minimum Data Set
A data set is a collection of information for assigned objectives and minimum data set (MDS)
is important data required as the minimum acceptable for the assigned purpose (AIHW 2012;
HIQA 2013). The main aim of health care standards is to improve quality of care, patient
safety and a reduction of incident and errors (HIQA 2012). The National E-Health Transition
Authority (NEHTA) (2006) in Australia proposes the use of standard clinical language to
communicate transition care to different health sectors. Studies by Chea et al (2005) and
Pagliary et al (2004) advocate the need for a minimum data set to communicate information.
Standardisation will improve the quality of discharge summary and saves time. A study by
Quin et al (2009) evaluated the process of handover of patients at four different organisations.
It reported that the availability of standard tools helps to maintain useful information which
could be useful to all organisations.
In Scotland, the immediate Scottish discharge summary was found to have deficits in content,
structure and production. These issues could be sorted by developing a minimum data set for
the maximum number of patients and these could be used as templates for discharge
summaries. The minimum data set can be used for system specification with a view to
electronic data transfer (Scottish Intercollegiate Guideline Network, 2008).
2.13 Benefit of Minimum Data Sets for Discharge Summary
In current situations, the minimum data set has drawn attention from health care professionals
due to improvement of technology and clinical terminology (Bean 2005; Butler 2006; Palases
et al 2013). In descriptive discharge summaries, the proper application of a minimum data set
is important for easy reading, comprehension and completeness. The structure design of the
discharge summary can be generated any time with a computer. Kripanali et al (2007)
19
discovered that GPs prefer a structured rather than a narrative format in the discharge
summary. AIHW (2014) recognised the requirement of nationally agreed, reliable and
standardised data for the discharge summary.
2.13.1 Benefit for Patients
The minimum data set will improve efficiency and safety of care (HIQA, 2013). It will
provide clarity about the meaning of each word on the discharge summary. It will improve
the accuracy and interpretation of data which can be shared safely with the primary care
team. It also reduces repetition, administrative costs and time (Rahaman 2014).
2.13.2 Benefits for the Primary Care Team
An ideal discharge summary contains high-standard minimum data which contributes to
better and safer care. It reduces cost and time by avoiding duplication of tests and
identification errors (HIQA 2013). The standard data set will improve communication
between hospital and the primary care team by speeding up the time it takes to share
information (Ahmadi 2015).
2.13.3 Benefits for the Hospital
The main benefit of the minimum data set is that it improves communication between the
hospital and primary care team. This will also provide accurate information sharing which
will ultimately reduce the number of readmissions (AIHW, 2011).
2.13.4 Other Benefits
The minimum data set facilitates consistency in content and data. The minimum data set has
international medical terminology which is beneficial for various purposes like decision
making, audit epidemiology, research, and policy making (Sermeus 2005). The minimum
data set also helps in conducting comparative studies on patient care, interventions, and
outcome.
2.14 Principle of Developing a Minimum Data Set
According to the Australian Institute of Health and Welfare (AIHW) (2011) the following
principles are applicable for the development of minimum data set:
20
Create the data standard. The data standard improves quality, consistency and
comparable data. Therefore, the development of a standard should follow the
operational procedure.
Application of national and international standard. The data set should be based
on a single agreed definition to ensure consistency and a reduction in cost and time
for data development.
Fulfil the aims of collecting data. The objective of data collection should be well
formulated ahead of developing the standard on the data set. Once the purpose is well
established, the objectives of data collection should be fulfilled to minimise the
expenses on generating, collecting, making the standard, and reporting of data.
Formulate once and use again. The data should be collected as a primary data set
which can be used as a secondary data set in policy making, governance, and research
purpose.
Awareness of limitation of data. Data can be used for one purpose but the same data
cannot be used for other purposes. For example, information about the number of
children is important for maternity settings but cannot be applicable for psychiatric
settings.
Development of data is autonomous. The data set should be well formulated and
standardised and generating of data should not be influenced by any means. There
should be agreement regarding privacy and security policy and its standard and
legislation. The developer should be familiar with national, international and health
related legislation.
Minimise the data collector’s workload. Development of data should reflect the
practice. The collection of data should be focused on feasibility, business needs,
scientific evidence and guideline of the subjects.
2.15 Development Process of the Minimum Data Set
Many organisations have roles in developing minimum data sets. Electronic health records
are necessary due to the advancements of ICT (Information Communication Technology) and
HIT (Health Information Technology). To fulfil the requirement of EHR (Electronic Health
Record) we need standard data. As per the principle of create once, use often, the objectives
of information management, development of data sets and standards require nationally agreed
guidelines and procedures to capture high quality data (Svensson-Ranello 2011). The
21
literature review suggested that there were various approaches used by many other
researchers for developing minimal data sets such as:
consultant hiring (Bean 2005),
making a team of experts or representatives (Ireland et al 2001),
committee of stakeholders (Evan et al 2010),
interview stakeholders (Evan et al 2010),
method of surveying (Mistry et al 2010),
Delphi technique (Bagley et al 2010),
literature review ( Ireland et al 2001),
use of data collection tool (Chan et al 2010).
The framework and standard tool developed by Svensson-Ranello (2010) used for
developing minimum data sets with multimode methods include reviewing patient records,
literature review, and expert opinion.
International guidelines recommended the use of a data dictionary worldwide. The main aim
of the data directory is to regulate the definition of data for reliability. In the UK, the NHS
developed an information centre to define the data. In Australia, the National Health Data
Dictionary is another source of information for data definition. Ireland uses HIPE (Hospital
Inpatient enquiry 2015) data dictionary and ICS (Irish Coding standard 2015) version 7.0
Editing ICD-10 for data definition.
HIPE (Hospital Inpatient enquiry) is designed to collect information about patient
demographic details, clinical, and administrative information on discharge and death from in-
patient service nationally.
The development of MDS should follow appropriate methodology to get quality data by
engagement with stakeholders. Svensson-Ranallo et al. (2011) proposed that clinical MDS is
developed through critical evaluation of the data elements (DEs) identified from literature
and patient chart. The domain expert evaluates the DEs through formal or informal process.
The proposed methodology for development of MDS is described in figure 2.2.
22
Figure 2.2: Development process of Minimum Data Set
Sources: Svensson-Ranallo et al. (2011)
“ICD-10 AM (Australian Modification) is combined with the Australian Classification of
Health interventions (ACHI), and the Australian Coding standard (ACS) to show the exact
symptoms of illness” (HIPE 2015; ICS 2015). AIHW (2007) published A Guide to Data
Development which provides “a body of expertise in data development.”
23
2.16 Privacy, Confidentiality, and Security
Privacy is the right of a person to keep the information about them, to disclose that to others
when the person so chooses, and for the person be free from interference from another
person, organisation or government (Rognehaugh 1999). Confidentiality refers to the
“treatment of information that an individual has disclosed in a relationship of trust and with
the expectation that it will not be divulged to others without permission in ways that are
inconsistent with the understanding of the original disclosure” (FDA 2013).
Security is defined as the extent to which personal data can be kept or shared among
authorized persons (Brander 2003).
Discharge summaries contain personal information therefore it needs to be kept private and
confidential. Every document involving research needs to be private and confidential. There
are various studies concerning privacy and confidentiality (Craig et al 2007). In a study
conducted in Austria by Schabetsberger et al (2006) it was reported that some health care
professions were apprehensive about the electronic transfer of documents and four GPs
refused to accept electronic documents at all. One psychiatric hospital refused to accept
discharge summaries due to the highly sensitive information relating to the patient. Paper-
based records may generate an extensive paper trail. Considering the developments in IT,
there is need to move discharge summaries from paper to electronic based system. Though,
electronic based records have many advantages, they need to be protected from a breach in
security. The main obstacle to the implementation of electronic health records are funding,
security, and privacy threat. The privacy and security of patient’s information is critical in the
health service sector. Studies conducted in various countries showed concerns regarding
privacy and security. In the US, there are 25 million cases of compelled authorization of
health records each year (Rothstein & Tolbot 2007). According to studies conducted in
Denmark, Germany, and New Zealand, respondents were concerned about data related to
EHR (Zurita et al 2004, Kirchner et al 2009, and Chhanabhai & Holt, 2007).
The biggest threats to e-health are accidental disclosure, abuse of health care privileges, and
access to information by an unauthorized third party.
Privacy, confidentiality and security should be maintained for discharge summaries whether
it is in a handwritten or electronic form. The paper discharge summaries should be kept in a
secure and confidential place which cannot be accessed by unauthorized people. Discharge
summaries can be sent by fax or email and even then its privacy and confidentiality should be
24
maintained. When discharge summaries are shared among health professionals, they should
be encrypted with strong passwords.
2.16.1 Encryption
Encryption is a method of protecting electronic information with a decryption key or
password. In Ireland the HSE Design Authority (2015) published a standard directory
outlining privacy, confidentiality and the security of data.
2.17 SNOMED-CT
SNOMED-CT is a guide of clinical terms used for documentation and reporting. It is useful
for coding, retrieving and analysing the data (International Health Terminology Standards
Development Organisation, SNOMED-CT® User Guide 2013).
In Ireland, health care link data is fragmented and stored in unconnected silos in various
systems. SNOMED-CT is the most inclusive nomenclature used in healthcare records. It is a
system of cross mapping with ICD-10 code which improves various areas such as
epidemiology, statistics, and administration work to international standards. SNOMED-CT
will minimise repeating requests for the same information.
2.18 Findings from Literature Review
After in-depth literature review, the researcher found the following findings:
Psychiatry care in Ireland-Most of the mental health service is carried out in
community. When patient is discharged, they refer to GPs for follow-up care. When
patient is discharged from hospital, discharge summary is generated whether in paper
form or electronic form.
Difference between generic and psychiatric discharge summary: There is wide
variation in contents of discharge summaries among different hospital which affecting
the continuity of care. Various details were omitted such as details on medication,
follow up care, physical examination and mental state examination.
Contents of discharge summaries: There are various organisations such as JCI,
NEHTA, and studies by various authors which highlighted the contents of discharge
summaries. There were variations in contents of discharge summary. HIQA published
an article o National Standard on Discharge Summary which provides guideline on
contents of discharge summary.
25
Discharge summary guideline in Ireland: HIQA is an independent body who
monitor quality care in Ireland provided the guideline for contents of discharge
summaries.
Challenges of the Discharge summary: The main challenges for discharge
summaries were delayed communication to primary care team, inclusion of inaccurate
and unnecessary information, omission of important contents, lack of information
about test conducted ,lack of information about outstanding results, and lack of
information about changes on medication. These challenges lead to readmission to
hospital, poor quality care, and increased risk of morbidity. There is need of timely
sharing of information to primary care team and minimum data set for discharge
summaries.
EU and International initiative related to discharge summary: Many countries
conducted various project to improve timely communication between hospital and
primary care team. In UK, Royal college of Physician, safety program in Scotland,
ACSQHC in Australia, various program in US were launched to improve the
discharge summary and its process. There is need of common discharge summary
within EU to improve the quality care.
Electronic Discharge summary: Electronic discharge summary (EDS) is developed
with advancement of Information technology. It is still debatable about quality of
EDS in comparison to handwritten summaries.
Development of Minimum data set: MDS is developed by using principle of data
development process. Various approaches were used by various researchers such as
hiring expert, making team of expert, committee of stakeholders, interview of
stakeholders, method of surveying, Delphi technique, literature review, and data
collection tool.
In literature review there is lack of standard content of discharge summary which is
important aspect of sharing information between hospital and primary care team. In
Ireland, there is no study done on GPs expectation in psychiatric discharge summaries.
2.19 Summary
Psychiatric care is the care given to mental health disorder patients during in-patient or
outpatient treatment. Psychiatric discharge summaries are the documents containing
26
information needed by the primary care team when the patient is discharged from hospital.
This transfer of information helps to support continuity of care. HIQA (2013) published the
National Standard for Patient Discharge Summary Information which outlines contents to be
included in discharge summary. Vital information is still lacking in the discharge summary of
psychiatric patients. National and International agencies took the initiative to standardise the
discharge summaries which will maintain quality, privacy, confidentiality, and security. The
development of MDS for the psychiatric discharge summary will improve the communication
gap and using information technology will improve the quality and timing of transferring the
information to the primary care team. The following chapter will outline the research
methodology.
27
Chapter 3
Research Design and Methodology
3.1 Introduction
This chapter includes details about the research design and methodology employed for this
study. It provides the rationale for choosing this particular research approach and design, and
the process applied to collect information for the study.
3.2 Research Approach & Design
The main aim of this dissertation is to explore the minimum dataset required for psychiatric
discharge summaries.
Figure 3.1 Conceptual framework for research design adapted from Crosswell (2013)
A research approach is defined as the “plans and the procedures for research that span the
steps from broad assumptions to detailed methods of data collection, analysis, and
interpretation” (Crosswell 2013). In this study, the researcher used three approaches,
qualitative, quantitative, and mixed, to answer the research question.
Creswell (1994) defines quantitative research as “explaining phenomena by collecting
numerical data that is analysed using mathematically based methods (in particular statistics)”
Therefore, it is essential to collect numerical data to explain the phenomenon by using
28
quantitative methods. Qualitative research is way of understanding underlying reasons,
opinion, and motivations.
The proposed research question is to investigate compliance with standard HIQA guidelines
for discharge summaries within an Irish hospital. In order to investigate this objective, a
thorough review of a wide range of resources is required. The researcher undertook an
exploratory method to identify the most common contents omitted from discharge
summaries. Considering the type of research needed to meet this study’s objectives, a mixed
research methodology including qualitative, quantitative and exploratory methods is required.
Mixed research is a mixture of both quantitative and qualitative research and it is better than
qualitative or quantitative alone. Mixed research works under the assumption of pragmatism.
The benefit of the mixed method is in comparing quantitative and qualitative (Creswell
2007). Many terms such as “integrating,” “synthesis,” “multi-method,” and, “mixed method”
are mentioned as synonyms in the literature. Recently, most researchers use the term “mixed
method” (Bryman 2006). Researchers used a sequential exploratory design which integrates
both qualitative and quantitative research. This type of design applies qualitative analysis
followed by collection and analysis of quantitative data.
After a detailed literature review on different types of research design, the researcher decided
that a mixed method with sequential explanatory design was the most appropriate method to
use in this study.
3.3 Research Methodology
Research methodology is the way of data collection, be it quantitative or qualitative, and the
analysed data helps us understand the study issues and allows the reader to critically evaluate
a study’s validity and reliability (Kallet Richard, 2004). As the researcher has chosen the
mixed method, the qualitative data is collected by reviewing the discharge summaries. Then
qualitative data is collected by using HIQA guidelines. After analysis, a minimum dataset
will be developed. The qualitative analysis is completed by gathering expert opinion on
discharge summaries. All of this will help to formulate the requirements for the discharge
summary.
Finally, the mixed methodology is used to collect the data for the MDS. After analysis of the
qualitative and quantitative data, a closed- and open-ended questionnaire and data collection
tool are then developed. Data is collected by survey method on GPs and a review of
discharge summaries against the standard minimum data set. Analysis was completed after
collecting data.
29
3.4 Research Design
The research design provides a plan of approach for a study (Creswell 2012) in helping to
identifying a problem, form research objectives, and set a framework on data collection,
analysis, interpretation, and reporting (Bogdan & Taylor 1975; Creswell 2012). The research
design for this study is mixed, a combination of quantitative and qualitative methods.
For this dissertation, the user requirement process consists of three components:
Context of use
User requirement specification
Prototype development
The following diagram describes the user requirement process; the arrow shows the next step
of process.
30
Context of use
User Requirement Specification
Template Development
& Evaluation
Figure 3.1 Schematic of user’s requirement process. Adapted from Brownsweel et al
2012.
3.4.1 Context of Use
There is a need for a systematic review of various studies to identify the initial minimum data
set. The researcher conducted an extensive literature review in relation to the formation of a
MDS for psychiatric patient discharge summaries.
3.4.1.1 Systematic Review
The researcher collected data for a comprehensive literature review on available databases
including PubMed, Wiley Online Library, Springer Link, Science Direct, Google, IEEE and
Scholars. During the search processes, a combination of different words was used. Figure 3.2
describes the research review process.
Requirement
Verification Template
Evaluation
Template
Development
User Requirement
Evaluation
Systematic
Review
Questionnaire
31
Figure 3.2 Research Review Process
The researcher searched the articles which met the search criteria. Once the criteria were met,
the researcher followed the references list and applied a snowball search strategy which is a
technique for finding research subjects. One subject gives the researcher the name of another
subject, who in turn provides the name of a third, and so on (Vogt, 1999).The snowball
search approach identified new articles not found in the initial search (Jalali & Wohlin 2012).
3.4.2 User Requirement Specification
Data collection requires the appropriate tool to help identify the minimum data set; a
combined method of data collection was used.
3.4.3 Template Development & Evaluation
A minimum data set for the collecting tool was developed by consultation with a consultant
psychiatrist, registrar of mental health service, community mental health nurse, and a
psychiatric nurse. These consultations were done during the researcher’s work experience in
the study hospital.
3.5 Tool Development Process
The draft of the MDS for the discharge summary was prepared and consists of demographic
details, primary care professional details, admission and discharge details, clinical details,
and follow-up care. The first draft was formed by following HIQA guideline and consulting
literature. Dr Eugene Breen, Consultant Psychiatrist gave his opinion on the MDS first draft.
The tool was developed based on the expert opinion and literature review, survey
questionnaire and chart review.
After the consultation process for tool development and a pilot study with a colleague, the
researcher changed the wording, rearranged some items, and provided more space to write
comments on each item. The results of the pilot study were not included in the research study
to avoid misleading results.
Discharge summary,
component of discharge
summary
Minimum data set,
development of data set,
content of data set
Discharge summary of
psychiatric patient, general
discharge summary,
standard of discharge
summary
32
3.6 Questionnaire
A questionnaire is a data collection tool comprising of a list of questions with advice on how
to complete the form (European Statistical System 2006). It gives freedom to the participant
to answer the questions and to provide an independent opinion without interference from the
researcher. The main benefit of a questionnaire is consistency and anonymity (Giesen 2012).
This study used a survey method where the participant completed the questionnaire and then
returned it to the researcher. The aim of the questionnaire was to collect information on the
surveyor’s opinion of the discharge summary contents, and feedback on data to be included
in future discharge summaries. The questionnaire was developed by using a STEPS
conceptual framework. This framework focuses on obtaining core data at each level on the
established risk factor. The STEPS approach has three levels and within each level, risk
assessment is categorised into core, expanded, and optional modules. Step 1 describes the
questionnaire based assessment or the core or minimum set (WHO 2016).
The questionnaire contains closed-ended questions to collect the participant’s opinion on
semi-structured data. Once developed, testing was carried out among working colleagues to
test possible mistakes in the questionnaire’s design and phrasing of questions. To test the ease
of completion and usability of the questionnaire, it was reviewed by the research supervisor
and a psychiatric expert. In the questionnaire, questions were asked on an “agree” or
“disagree” basis. When the participant agreed, they go on to choose a “mandatory”,
“optional” or “conditional” statement on each question.
3.7 Data Collection Tool
The collection tool for reviewing the data was developed after the questionnaire. The number
of items in the collection of tool was the same as the questionnaire. The data was collected in
terms of “yes” or “no” answers.
3.8 Participant Recruitment Methods
In this dissertation, there are two sample categories. Firstly, 100 psychiatric patient discharge
summaries were selected randomly from the total amount of patient discharges in 2015. The
sample size was selected from the total discharge summaries of patients admitted in 2015, of
which there were 205. The sample was chosen by a random sampling technique. Secondly,
50 GPs were specifically selected from the list of GPs on the HSE website. Participants were
invited to take part in the research study by sending questionnaires attached with a cover
33
letter (Appendix 7), participant’s consent forms (Appendix 5) and information leaflets
(Appendix 6). The participant information sheet included the aims of the study and a request
for participants. The information sheet included the statement “All participants have the right
to take part or to pull out from the study at any time without any compensation.”
In total 50 questionnaires were posted to GPs working in North Dublin City. An envelope
containing research questionnaires with instructions, consent forms, participant information
sheets, and a return envelope with stamp were posted to the GPs’ addresses.
A cover letter and consent form (Appendix 7 & 5) informed the participants that answers
were confidential and they would be non-identifiable during the study and their data would
keep confidential under the Data Protection Act, 1988 and Data Protection Act Amended
2003.
3.8.1 Inclusion Criteria
The study included all discharge summaries as planned discharges in 2015.GP working in
Dublin North were included as participants.
3.8.2 Exclusion Criteria
Discharge summaries which are difficult to read and written of paper were excluded from
study. Patients re-admitted in the same year of patients’ discharge summary were excluded.
Patient who left hospital against medical advice (DAMA) were not included in study. GPs
not giving consent for participation were excluded from study.
3.9 Validation
The validation was done with the standard developed by HIQA (2013) and a review of
literature.
3.10 Ethical Approval
This study was approved by the research ethical committee of MMUH (Appendix 2) and the
School of Computer Science and Statistics of Trinity College (Appendix 1). The researcher
was assured compliance with the principles of autonomy, beneficence, and maleficence,
justice and the Data Protection Act, 2003. Written consent was obtained from participants
involved in the research study.
34
3.11 Data Analysis
Descriptive analysis and Microsoft Excel spread sheets were used to analyse the collected
data. The researcher followed the HIQA (2013) data analysis guidelines in analysing the
collected data. The data was recoded on an Excel workbook. The agreed mandatory, optional,
or conditional responses from participants were also recorded in a database. A data set with
80% or more agreed mandatory responses were considered as the mandatory data set for
discharge summary. A data set with 80% or more disagreed were considered as disagree.
3.12 Summary
This chapter outlines the methodology of developing the MDS for the psychiatric discharge
summary. This research study uses the mixed method of sequential explanatory research
design. The national and international standard was used to develop the MDS. The study was
categorised into two parts, the first part is a collection of data from 100 discharge summaries
at the study hospital, which were selected at random from 205 discharge summaries in 2015.
In the second phase, 50 GPs were specifically selected from the HSE website to collect data
by sending a questionnaire by post. Data analysis was done by using descriptive analysis and
the ethical process was applied throughout the data collection.
Chapter 4 outlines the findings of this study. Chapter 4A describes the findings of reviewing
the hospital discharge summaries and Chapter 4B describes the results of GP opinion on the
minimum data set.
35
Chapter 4
Results, Analysis, & Discussion
4.1 Introduction
The mental health service is a vital part of a country’s health care system as it is needed at
some time or another through a person’s life. All mentally-ill people should have access to
high quality and high standards in the mental health care system. An ideal mental health care
system depends on high quality information sharing. The discharge summary is an important
way of sharing information between the hospital and the primary care team. In the process of
developing the minimum data set for the discharge summary, this study reviewed the
discharge summaries of mentally-ill patients admitted to the psychiatric ward of MMUH,
Dublin. A survey of GPs’ opinions on the discharge summary was also conducted for this
study. This chapter discusses the findings of the discharge summary review. Each discharge
summary was studied for its content and entered into a Microsoft Excel sheet for descriptive
analysis. The results are illustrated in the form charts, graphs, and tables. Section 4.3
describes the GPs’ views on the discharge summary content and their responses are analysed
in a descriptive frequency. The results describe the contents to be included in the discharge
summary shown in form of a graph, chart, and table.
Of the 50 questionnaires sent out to GPs in the North Dublin City area, only 12
questionnaires were returned. All returned questionnaires were included in the research study
as all met the study criteria.
4.2 Contents of Discharge Summary
4.2.1 Patient Details
Most of the discharge summaries included important patient details such as name, address,
date of birth and individual health identifier whereas few details were omitted from the
majority of the discharge summaries. The patient’s name was present in all discharge
summaries. The length of stay in the patient’s current address was missing in all summaries.
The discharge destination, length of stay in current address, nationality and next of kin were
identified as missing contents in the majority of discharge summaries. Figure 4.1 describes
the frequency of patient details in the discharge summaries.
36
Figure 4.1 Frequency of Contents of Patient Details in Discharge Summaries
4.2.2 Primary Healthcare Professional Details
The majority of discharge summaries (66%) contained the name, address, and phone number
of GPs whereas email, community care service, and GP ID number were missing in almost
all discharge summaries. Figure 4.2 shows the primary health care details included and
omitted from discharge summaries.
Figure 4.2 Frequency of Primary Healthcare Professional Details
100 92
98 97
3 0 2 2 0 8
2 3
97 100 98 98
0
20
40
60
80
100
120
Name Address Date of birth
Health identifier
Discharge destination
address
Length of stay in current address
Nationality Next of kin
Patient Details
Yes No
66 66 66
0 1 0
34 34 34
100 99 100
Name of GP Address of GP
Phone number of
GP
E-mail Community care service
GP identification
no
Primary Care Healthcare Professional Details
Yes No
37
4.2.3 Admission & Discharge Details
The majority (80%) of discharge summaries contained the date of admission and the date of
discharge. About 9% of discharge summaries contained the discharge method. The source of
referral, method of admission, and reason for admission was present in 64% of discharge
summaries. The date of death and post-mortem flag were omitted from all discharge
summaries. Almost half of the discharge summaries noted the treating consultant. Only 14%
of discharge summaries showed the legal status for psychiatric patients. Figure 4.3 shows the
admission and discharge details.
Figure 4.3 Frequency Percentages of Admission & Discharge Details
4.2.4 Clinical Information
Almost 75% of discharge summaries contained presenting complaints, ICD diagnosis,
progress, treatment during admission, and discharge medication. Most of the discharge
summaries, that is more than 90%, were missing past medical history, pre-morbid
personality, physical examination, and risk factor. Only less than 50% of discharge
summaries were missing past psychiatric history. Family history and social history were
omitted from 88% percent of discharge summaries. Figure 4.4 describes the clinical
information present or absent from the discharge summary.
88 70 64
76 83
9 0 0
49
14 12 30 36
24 17
91 100 100
51
86
0
20
40
60
80
100
120
Admission & Discharge Details
Yes No
38
Figure 4.4 Frequency Percentages of Clinical Information Details
4.2.5 Future Management
Out of 100 discharge summaries, only 40% of discharge summaries showed future
management as hospital action. Most of the discharge summaries (about 90%) presented no
future management plan after discharge. The contents which were omitted from discharge
summaries include GPs’ action, social care action, information given to patient, advice and
recommendations, number of pages, place the patient was discharged to, and consultant
details. Figure 4.5 describes future management details included and omitted from the
discharge summary.
75
44
12 6 12 8 2
38
2 8
77 79 73
4 25
56
88 94 88 92 98
62
98 92
23 21 27
96
Clinical Information
Yes No
39
Figure 4.5 Frequency percentage of future management details included in or omitted from
discharge summaries.
4.2.6 Details of the Person Completing the Discharge Summary
The discharge summaries typically include three details of the people completing the
discharge summary such as the name of person completing the discharge summaries, their job
title, and their signature. Contact numbers and ‘copy to’ were missing from almost all
discharge summaries. Only 80% of discharge summaries contained the signature of person
completing discharge summaries while 84% of discharge summaries were missing the date of
completion.
41
10 11 15 20
2 3 5 1
17
1 0
59
90 89 85 80
98 97 95 99
83
99 100
Future ManagementChart
Yes No
40
Figure 4.6 Frequency of details of the person completing the discharge summary
4.2.7 Review of Discharge Summary in Hospital
The chart review was conducted on 100 discharge summaries. The contents of the discharge
summaries were calculated based on the findings of study. The contents which were omitted
80% or more times in 80% of the discharge summaries were considered as omitted contents.
This study suggested that there were various contents which were omitted from summaries.
In patient’s details, the omitted contents were discharge destination address, length of stay in
current address, nationality, and next of kin. However, the National Standard for Patient
Discharge Summary Information (HIQA 2013) suggested that discharge destination address
can be kept as optional in the patient details section of discharge summaries. The patient
details section fully complied with HIQA (2013) guideline. The discharge destination address
is important as it can affect the patient’s rehabilitation. The primary healthcare professional’s
details were present in all discharge summaries. Regarding admission and discharge details,
the discharge method was missing in most of the charts. However, the HIQA (2013)
guidelines state that the discharge method is mandatory where applicable. In a similar way,
there were few contents missing in discharge summaries such as date of death, and post-
mortem flag. These are mandatory (where applicable) components of discharge summaries,
but these are not applicable for reviewing chart.
Most of the clinical information contents omitted from discharge summaries included family
history, past medical history, social history, occupational history, pre-morbid personality,
physical examination, investigation, and risk factors. These contents are important details.
Future management was missing in all discharge summaries except hospital actions although,
future management contents are mandatory but only where applicable according to HIQA
97
0
99 80
99
1
84
3
100
1 20
1
99
16
Person completing
name
Contact number
Job title Professional body
registration number
Signature Copy to Date of completing of
discharge summary
Person completing discharge summary details
Yes No
41
(2013) guidelines. The future management plan for mentally-ill patients is important for
continuity of care. The omitted contents for details of the person completing the discharge
summary included the contact number and copy to. The contact number is mandatory
whereas copy to is optional as per HIQA (2013) guidelines for discharge summaries. Table
4.1 describes the omitted contents in discharge summaries.
Table 4.1 Omitted Contents of the Discharge Summary
A.
Patients details (Omitted in
discharge summary)
B.
Primary healthcare
professional details (Omitted
in discharge summary)
1. Discharge destination address 1. Email
2. Length of stay in current
address
2. Community care service
3. Nationality 3. GP Identification
4. Next of kin
C.
Admission and discharge
details omitted from discharge
summary
D.
Clinical information details
omitted from discharge
summary
1. Discharge methods 1. Family history
2. Date of death 2. Past medical history
3. Post-mortem 3. Social history
4. Legal status 4. Occupational history
5. Pre-morbid personality
42
6. Physical examination
7. Investigation
8. Risk factor
E.
Future management details
omitted in discharge summary
F.
Person completing summary
details omitted in discharge
summary
1. GP’s action 1. Contact number
2. Social care action 2. Copy to
3. Information given to patients
and carer
4. Advice, recommendation, and
future plan
5. Number of pages
6. Place discharged to
7. Consultant sign-off
8. Date of consultant sign-off
9. Discharge speciality
10. Document reference number
4.3 GP Opinion on Discharge Summary
4.3.1 GPs Opinion on Demographic Details
According to the survey on GPs regarding discharge summaries all participants agreed that
the name, address, DOB, individual health identifier, discharge destination address, and next
of kin should be included as part of the demographic details in discharge summaries. About
43
91% of participants agreed on nationality to be included in discharge summary. Only 75% of
GPs agreed on length of stay in current address to be part of discharge summaries. All
participants agreed on name, address and DOB as mandatory components of demographic
details in discharge summaries. Half of the participants agreed on the individual health
identifier and nationality as optional components of the discharge summary. The majority of
participants (83%) agreed on the discharge destination address as a mandatory component.
There was mixed agreement as to mandatory, optional, or conditional on contents such as
length of stay at current address and next of kin. Figure 4.7a and Figure 4.7b describe the
frequency percentage of GP’s opinions on demographic details.
Figure 4.7a Frequency of GPs’ Opinions on Demographic Details
100% 100% 100% 100% 100%
75% 91.60%
100%
0 0 0 0 0
25% 8.40%
0
Name Address Date of birth Individual health
identifier
Discharge destination
address
Length of stay in current address
Nationality Next of kin
Demographic Details
Agree Disagree No Answer
100% 100% 100%
50%
83.30%
16.60%
33.30%
50%
0 0 0
50%
16.60%
33.30%
50%
16.60%
0 0 0 0% 0
16.60%
0%
16.60%
0 0 0 0% 0
33.30%
16.60% 16.60%
0%
20%
40%
60%
80%
100%
120%
Name Address Date of birth Individual
health identifier
Discharge
destination
address
Length of stay
in current
address
Nationality Next of Kin
Demographic details
Mandatory Optional Conditional No Answer
44
Figure 4.7b Frequency of GPs’ Opinions on Demographic Details
4.3.2 GP’s Opinion on Primary Healthcare Professional Details
All GPs agreed that the name and address of GPs should be included in discharge summaries.
It is evident from Figure 4.9 that only 75% of participants were in favour of the GP’s phone
number to be included. About 58% of participants were not in favour of email and GP ID to
be included in the discharge summary. Out 83% of participants said that the name and
address of the GP should be a mandatory component of the discharge summary. About 16%
of participants agreed that the email address should be optional and conditional components
of discharge summary. One third of participants agreed that the GP’s phone number should
be included as mandatory and optional.
Figure 4.8a Frequency of GPs’ Opinions on Primary Healthcare Professional Details
100% 100%
75%
25%
66.66%
16.66%
0 0 8.33%
58.33%
8.33%
58.33%
0 0
16.66% 16.66% 25% 25%
Name of GP Address of GP Phone Number E-mail Community care service
GP identification number
Primary Healthcare Professional details
Agree Disagree No Answer
45
Figure 4.8b Frequency of GP’s Opinions on Primary Healthcare Professional Details
4.3.3 GP’s Opinions on Admission & Discharge Details
All participants were agreed on the date of admission, source of referral, method of
admission, reason for admission, date of discharge, place to discharge, date of death (where
applicable), and treating consultant to be components of the admission and discharge details
on the discharge summary. Only 75% of participants were in favour of the post-mortem to be
included in discharge summaries. The mandatory component of discharge summaries were
date of admission, source of referral, method of admission, reason of admission, date of
discharge, and treating consultant was agreed by all participants.
Figure 4.9a Frequency of GPs’ Opinions on Admission and Discharge Details
83.30% 83.30%
33.30%
0%
16.60% 16.60%
0 0
33.30%
16.60%
50%
16.60%
0 0 0
16.60%
0 0%
16.60% 16.60%
33.30%
66.60%
33.30%
66.60%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Name of GP Address of GP Phone Number E-mail Community care
service
GP Identification
number
Primary Healthcare professionals Details
Mandatory Optional Conditional No Answer
100% 100% 100% 100% 100% 100% 100%
75%
100%
0 0 0 0 0 0 0 8.40%
0 0 0 0 0 0 0 0 16.60%
0
Date of admission
Source of referral
Method of admission
Reason of admission
Date of discharge
Place discharge to
Date of death Post-mortem flag
Treating consultant
Admission & Discharge Details
Agree Disagree No Answer
46
Figure 4.9b Frequency of GPs’ Opinions on Admission and Discharge Details
4.3.4 GPs’ Opinions on Clinical Information
In this section eighteen data sets were included in draft discharge summaries. Out of 18
components, 8 data sets were agreed upon by all participants. The agreed data sets were
presenting complaints, past psychiatric history, family history, pre-morbid personality,
mental state examination, discharge medication, patient follow-up plan, and advice to GP. It
is evident from figure 4.10a that just more than 80% of participants were agreed on past
medical history, social history, occupational history, physical examination, ICD-10 diagnosis,
progress and treatment during admission, place discharge to, and number of pages were to be
included in the discharge summary. Figure 4.10b shows that all participants were agreed on
presenting complaints, discharge medication, and patient follow-up plan as mandatory
components of the discharge summary. The same numbers of participants were agreed on
family history as an optional component of discharge summaries. There were mixed
responses on the data set regarding occupational history, pre-morbid personality, and
investigation as mandatory, optional, or conditional components of the discharge summary.
100% 100% 100% 100% 100%
83.30%
66.60% 66.60%
100%
0 0 0 0 0
16.60%
0 0 0 0 0 0 0 0 0
33.30%
16.60%
0
0%
20%
40%
60%
80%
100%
120%
Date of
admission
Source of
referral
Method of
admission
Reason for
admission
Date of
discharge
Place
discharge to
Date of
death
Post-mortem
flag
Treating
consultant
Admission & Discharge Details
Mandatory Optional Conditional No Answer
47
Figure 4.10a Frequency of GPs’ Opinions on Clinical Information
Figure 4.10b Frequency of GPs’ Opinions on Clinical Information
4.4 Minimum Dataset for Psychiatric Discharge Summaries
The minimum data set is developed from the research findings. The data set is selected from
the analysed results of the GP survey. The data sets commonly used in hospitals are not data
100% 100% 100%
83.30% 91.60%
91.60%
100% 100% 91.60%
75% 91.60%
91.60% 91.60%
100% 91.60%
100% 100%
50%
0 0 0
16.60% 8.40% 8.40%
0.00% 0.00% 8.40% 8.40% 8.40%
0.00% 0.00% 0.00% 0.00% 0 0 0 0 0 0 0 0 0
0 0
0
16.60%
0 8.40% 8.40% 0.00% 8.40% 0.00% 0.00%
50%
0%
20%
40%
60%
80%
100%
120%
Clinical Information
Agree Disagree No Answer
100%
83.30%
0
50% 50%
16.60%
66.60%
66.60%
16.60%
0.00%
33.30%
66.60%
66.60%
100%
66.60%
100%
83.30%
33.30%
0
16.60%
100%
33.30%
50%
83.30%
33.30%
16.60%
66.60% 66.60%
50%
16.60% 16.60%
0 0 0
16.60% 16.60%
0 0 0 0 0 0 0 0 0 0 0 0 0 0 16.60%
0 0 0 0 0 0
16.60%
0 0 0
16.60% 16.60% 33.30%
16.60%
16.60%
16.60%
0
16.60%
0 0
50%
0%
20%
40%
60%
80%
100%
120%
Clinical Information
Mandatory Optional Conditional No Answer
48
dictionaries. The data set agreed upon by more than or equal to 75% of the participants were
included in the minimum data sets.
The data definitions for this study are formed based on the HIQA (2013) National Standard
for Discharge Summary Information. It is evident that psychiatric discharge summaries need
to include various data sets to complete an ideal psychiatric discharge summary. These data
sets need to be improved periodically based on internationally used data definitions.
The optionality column describes the recommendation for inclusion of data. The participant’s
choice to choose the data to be mandatory, optional, or conditional depends on their
information needs. The mandatory data is the important piece of information and cannot be
completed without this data set. The optional data is not mandatory but can be included as per
local policy.
This study suggests the need for SNOMED-CT in the minimum data set. The discharge
summary is described in headings such as demographic details, primary healthcare
professional details, admission and discharge details, and clinical information. The table 4.2
below describes the minimum dataset for psychiatric discharge summary.
49
Table 4.2 Minimum Dataset for Demographic Details
No. Data Set Definition & Source of
Definition
Optionality SNOMED-
CT
Name and
Concept ID
1. Name
(Forename and
Surname)
(HIQA 2013)
A patient’s first name or given
name as per birth certificate.
The second part of name which
denotes their family or marital
name.
Mandatory Demographic
History
details
(Observable
entry)
Concept ID:
703503000
1. Address
(HIQA 2013)
The particular of the place used
to correspond with the
patient’s primary healthcare
professional.
Mandatory Patient
address
(observable
entry)
Concept ID
184097001
2. Date of birth
(HIQA 2013)
Date of birth indicating the
day, month, and year when the
patient was born.
Mandatory Date of Birth
(Observable
entry)
Concept ID:
184099003
3. Discharge
Destination
address (HIQA,
2013)
The place the patient is
discharged to
Mandatory Not available
50
Table 4.3 Minimum Dataset for Primary Healthcare Professional Details
No.
Data Set Definition & Source of
Definition
Optionality SNOWME
D-CT
Name and
Concept ID
1.
1
Name of the
primary care
professional
(HIQA 2013)
First name and surname of the
primary healthcare professional
Mandatory Concept
ID:7039780
00
2.
2
Address
(HIQA 2013)
The particular of the place used
to correspond with the patient’s
primary healthcare professional
Mandatory Not
Available
51
Table 4.4 Minimum Data Set for Admission & Discharge Details
No. Data Set Definition &
Source of
Definition
Optionality SNOMED-CT
Name and Concept
ID
1
Date of admission
(HIQA 2013)
The date at which
patient was admitted
to hospital ward
Mandatory Concept ID
399423000
2
Source of referral
(HIQA 2013)
This describes who
made the decision to
refer the patient to
the hospital
Mandatory Not available
3 Method of
admission
The circumstances
under which a
patient was admitted
to the hospital
Mandatory Not available
4 Reason of
admission
The diagnosis
established after
study to be chiefly
responsible for
occasioning an
episode of admitted
patient care &
conditions or
complaints either
coexisting with the
principal diagnosis
or arising during the
episode of admitted
patient care
Mandatory Reason for admission
(record are fact)
Concept
ID:886861000000108
This is a UK specific
concept
5 Date of discharge The circumstances Mandatory Date of discharge
52
(HIQA 2013) under which a
patient left the
hospital
(Observable entity)
Concept
ID:442864001
6 Place discharge to The place discharge
to indicate address
when patient left the
hospital
Optional Not available
7 Treating
consultant
The name of
consultant under
whom patient was
admitted
Mandatory Not available
53
Table 4.5 Minimum Data Set for Clinical Information
No. Data Set Definition & Source of
Definition
Optionality SNOMED-CT
Name and Concept
ID
1 Presenting
complaints
The reason for which
patient was admitted to
hospital
Mandatory
2 Past
psychiatric
history
Psychiatric problem
occurred in past before
present problem
Mandatory
3 Family history If the result reported in
this field affects the
management of the
mental illness
Optional Family history of
clinical findings
Concept
ID:416471007
4 Occupational
History
If the result reported in
this field affects the
management of the
mental illness
Optional Not Available
5 Discharge
Medication
(HIQA)
The medication the
patient is intended to take
after they have been
discharged
Mandatory Not available
6 Patient follow-
up plan
Any plan of care needed
by treating team when
discharging patient
Mandatory Not available
7 Advice to GP Any advice related to
patient care decided by
treating team when
discharging patients
Mandatory Not Available
54
4.5 Summary
This chapter discussed the results of the reviewed discharge summaries in the study hospital
and the GP views on the contents of discharge summaries. While most of the data was agreed
upon, many more contents were not presented and not agreed by GPs. It was clear from this
study that not all components of discharge summaries are needed as per the opinion of GPs in
comparison to HIQA guidelines.
55
Chapter 5
Conclusion & Future Work
5.1 Introduction
The aim of this research was to investigate compliance in regards to the contents of discharge
summaries with HIQA guideline. The literature review identified the most frequent omitted
contents in discharge summaries such as GP information, admission details, and clinical
information gaps in communication between hospital and community service team. A
methodology for developing the ideal discharge summary was identified to answer such
research questions as to what extent discharge summaries are complying HIQA guidelines,
what are the deficit areas in the discharge summary, and what do GPs want in discharge
summary.
5.2 Key Findings
The data set currently available for psychiatric discharge summaries has to be further
developed to provide adequate information for continuity of care.
The developed discharge summary data sets need further research in relation to
SNOMED-CT.
The research findings suggest that there is a need for a separate psychiatric discharge
summary which has a unique dataset.
The research has the potential to contribute to the future development of a minimum
data set for a psychiatric discharge summary which will ultimately become a national
psychiatric discharge summary.
The research findings also showed that there is need for a standard data set for
psychiatric discharge summaries.
5.3 Achievement of the Objective & Research Question
The first objective was to determine compliance HIQA guidelines regarding the
contents of discharge summaries and its results are described in Chapter 4, section
4.2.
The second objective was to identify the omitted contents in discharge summary. This
is discussed in Chapter 4, section 4.2.7.
56
The third objective was survey GP’s expectations in regards to the contents of
discharge summaries and these findings are described in Chapter 4, section 4.3.
The fourth objective was to develop a paper-based discharge summary template and
its results and templates is discussed in Chapter 4, section 4.4.
5.4 Recommendations for Future Work
This study found a lack of adequate data sets for discharge summaries for psychiatric
patients, therefore, there is need for further exploration of psychiatric data sets and
developments in psychiatric data dictionaries are suggested.
There is not much literature on psychiatric discharge communication in Irish publications and
there is need of further study to find out the efficacy of minimum data sets for a better
understanding of the information requirements of all teams involved in psychiatric care
service.
The current study found that psychiatric datasets is an under-researched area which needs
further exploration.
This study, conducted in accordance with HIQA guidelines, also shows a need for further
exploration of SNOWMED-CT and how it can assist in the Irish psychiatric service.
A research into the accuracy or completeness of existing discharge summaries is beyond the
scope of this study but future studies in this area should be encouraged.
5.5 Limitations of the Study
This study is dependent on the current data set which is drawn from various national and
international sources which may lack authenticity. Based on the available data set, there was
a long list of contents for the questionnaire.
This study was limited to one hospital and consequently may not be representative of other
hospitals in Ireland. Similarly, as only GPs from North Dublin City were surveyed, these
findings may not be applicable on a national scale.
The sampling technique was deliberate; however, samples could be selected randomly from
total sample size. It also lacks generalisation.
There was limited number to the sample size which is not representative of Ireland’s entire
population.
57
Chapter 6
Summary
The primary care team is an important aspect of the Irish health care system in caring for
mentally-ill patients. This is well-documented in literature but a rarely researched area is the
contents of discharge summaries which is important aspect in transfer of care. The literature
review suggests that psychiatric discharge summaries are an under-researched area. This
study showed that there is a lack of content and quality data sets in the psychiatric discharge
summary and expectation of GPs of discharge summaries.
The main objective of the research was to develop a minimum data set for psychiatric
discharge summaries. The study objectives were to determine compliance with HIQA
guidelines for content, to identify the specific areas of deficit in the discharge summaries, to
develop a minimum data set for contents of discharge summaries from GPs and develop a
template for an electronic version of the discharge summary.
To fulfil these aim and objectives, a mixed methodology of sequential, descriptive, and
exploratory research design was applied for development of the minimum data set. The phase
system was used to develop the minimum data set. Firstly, discharge summaries were
collected from the study hospital and quantitative data was analysed to discover the existing
data. Secondly, the draft of the minimum data set was developed according to findings of the
literature review and HIQA guidelines. Thirdly, a survey questionnaire was posted to 50 GPs
and an extensive review was done on 100 patient’s charts. Finally, the collected data was
analysed to develop a final minimum data set.
The analysis of the chart review showed that there were various contents omitted from
discharge summaries especially in clinical information section and the admission and
discharge details section. There were mixed responses on primary healthcare professional
detail contents. This study found major gaps between hospital and community care as GPs
expect more information, but hospitals give little information which calls into question the
quality of follow-up care.
The final template for the minimum data set was developed based on the findings of the chart
audit and GP survey. The minimum data set is classified under four sections such as
demographic details, primary healthcare professional details, admission and discharge details,
and clinical information.
One of the biggest challenges was defining the data sets using current data available in
Ireland therefore data from another source had to be included. In this study, the researcher
58
found the need to inclusion SNOMED-CT in minimum data set. It will help to achieve the
aim of interoperability. This study also found that the standardisation of data across Ireland
will resolve the information inequalities. The main limitation of study was:
Small number of sample size
Sampling technique was deliberate
Sample was selected from one study hospital and GPs of North Dublin City
This study also found that there is need for further study on a national scale.
59
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Appendix 1
Research Ethical Committee Approval Letter, TCD
70
Appendix 2
Research Ethical Committee Approval Letter, MMUH
71
Appendix 3
Research Ethical Committee Application Cover Letter, MMUH
72
Appendix 4a
Permission Letter from Consultant Psychiatrist, MMUH
73
Appendix 4b
Permission Letter from Consultant Psychiatrist, MMUH
74
Appendix 4c
Permission Letter from Consultant Psychiatrist, MMUH
75
Appendix 5
Participant’s Consent Form
TRINITY COLLEGE DUBLIN
INFORMED CONSENT FORM
LEAD RESEARCHER: Anil Kumar Deo
Supervisor Prof. Gaye Stephens
BACKGROUND OF RESEARCH
Discharge summaries are an important tool of sharing information between hospital and
primary care team. Low quality of discharge summary is a principal cause of poor
communication which has negative impact on patients care. Although, HIQA (2013) have
developed National standard for discharge summary, psychiatric discharge summary need
specific requirements regarding information they need to share between hospital and primary
care team. This study is being conducted to contribute to developing a minimum dataset for
an ideal psychiatric discharge summary.
In Ireland, HIQA developed a National standard for discharge summary information. This
document aims tobe a generic data set and some clinical specialties such as psychiatric care
settings, require additional specific requirements regarding the information they need to share
with primary care team.
PUBLICATION:
Once analysed, the information will be used in preparing a final dissertation and will be
submitted to a university (Trinity College- Dublin).. A poster presentation will be prepared to
disseminate the findings from this study.
DECLARATION
I am 18 years or older and am competent to provide consent.
I have read, or had read to me, a document providing information about this
research and this consent form. I have had the opportunity to ask questions and all
my questions have been answered to my satisfaction and understand the
description of the research that is being provided to me.
76
Individual results may be aggregated anonymously and research reported on
aggregate results.
I agree that my data is used for scientific purposes and I have no objection that my
data is published in scientific publications in a way that does not reveal my identity.
I understand that if I make illicit activities known, these will be reported to appropriate
authorities.
I freely and voluntarily agree to be part of this research study, though without
prejudice to my legal and ethical rights.
I understand that I may refuse to answer any question and that I may withdraw at any
time without penalty.
I understand that my participation is fully anonymous and that no personal details
about me will be recorded.
I have received a copy of this agreement.
------------------------------------- ------------------------------ -------------
-------------------
Participant Name Participant’s Signature
Date
Statement of investigator’s responsibility: I have explained the nature and purpose of this
research study, the procedures to be undertaken and any risks that may be involved. I have
offered to answer any questions and fully answered such questions. I believe that the
participant understands my explanation and has freely given informed consent. If participant
has any query can contact me as details below.
RESEARCHERS CONTACT DETAILS:
Anil Kumar Deo, Clinical Nurse Manager, St Aloysius Ward, Mater Misericordiae University
Hospital, Dublin-7.
E-mail [email protected] Phone No. 0876773075
INVESTIGATOR’S SIGNATURE:
Date:
77
Appendix 6
Participant’s Information Leaflet
Participant’s Information Leaflet.
You are being invited to take part in a research study. Before you decide whether or not you
wish to take part, you should read the information provided below carefully. You should
clearly understand the risks and benefits of taking part in this study so that you can make a
decision that is right for you. You should be 18 years old and should be competent to provide
consent. You do not have to participate in this research if you do not wish to do so. Your
participation is fully anonymous and that no personal details about you will be recorded.
Study Title:
Exploration of discharge summary of Psychiatric patient admitted.
Researcher Name: Anil Kumar Deo
Course: Second year M.Sc. Health Informatics, Trinity College, Dublin
Research Supervisor Name: Prof. Gaye Stephens, Trinity College, and Dublin.
Principal Investigator: Dr Eugene Breen, Consultant Psychiatrist, Mater Misericordiae
University Hospital, and Dublin 7.
Introduction This study is intended to develop minimum data set for psychiatric discharge summary from
study hospital. In Ireland, HIQA developed a National standard for discharge summary
information. This document aims to be a generic data set and some clinical specialties such as
psychiatric care settings, requires additional specific requirement regarding the information
they need to share with primary care team. This study intends to define high quality discharge
summary for discharging patients to primary care team.
Who is organizing and funding this study?
A Second Year M.Sc. Health Informatics TCD student is carrying out this research. This
research is not being funded by any third party and will not yield any financial gain for the
researcher.
78
How can you contribute?
As a part of the study the researcher seeks to get expert opinion from health professionals
involved in mental health service services to develop a minimum data set for psychiatric
discharge summaries. The responses to the questionnaire are sought from General
Practitioners. You can contribute by agreeing to take part and answering the questionnaire.
What do you have to do?
If you agree to take part in this study, you will be asked to sign a consent form prior to
participation. You will be given a questionnaire to complete. You will not be required to
provide any personal data and all questionnaires will be anonymous. The expected duration
of time to complete the questionnaire is 20 to 30 minutes.
Who will be conducting the data collection?
A Health Informatics student, who is a clinical Nurse Manager, under the supervision of Prof.
Gaye Stephens from Trinity College, Dublin.
What are the possible risks taking part in this research study?
There are no foreseeable risks to you in taking part in this study.
What are the benefits in taking part in this study?
While there are no immediate benefits to you, your participation will provide important
information on discharge summaries in psychiatric service in Ireland. Other benefits are,
1. The minimum data set could improve the efficiency of discharge process, and assist
the coders in ensuring high quality data for hospital inpatient enquiry system
2. Minimum data sets are the basis for electronic discharge summaries, which will lead
to a more timely transmission of information between secondary/tertiary care and
primary care and reduce the need for duplicate data entry.
3. National Benefit - The developed minimum data set from this study could be used as
a national standard for psychiatric discharge summaries in Ireland.
What measures will be taken to ensure confidentiality?
You will not be required to provide any personal data and all questionnaires will be
anonymous.
79
What will happen after the data collection is completed?
The researcher will analyze the data in order to provide a descriptive understanding of the
data. Anonymity will be preserved all through analysis, publication, and presentation of
resulting data and findings.
How will be the information stored and used?
The information will be stored in digital form in a password-protected computer and as a
written transcript in a locked filing cabinet in psychiatric ward.
How will be the information reported?
Once analysed, the information will be used in preparing a final dissertation and will be
submitted to a university (Trinity College- Dublin). A full report will be submitted to the
study Hospital. A poster presentation will be prepared to disseminate the findings from this
study.
Has the study been approved by an ethical committee?
Yes , researcher got ethical approval from Trinity College Dublin
Declaration of Conflicts of Interest
This study involves no conflicts of interest that would affect the participant’s decision to take
part or withdraw from the study at any time.
Is there provision for debriefing after participation for this study?
If the participants wish to obtain further information, please contact: Anil Kumar Deo E-mail:
80
Appendix 7
Cover Letter for General Practitioners
Anil Kumar Deo Date: -
71 Adamstown Way
Adamstown
Co. Dublin
0876773075
GP Name
GP address
Dear Doctor,
I am a final year student in Trinity College, Dublin, completing an MSc in Health
Informatics. My research Dissertation is “An Exploration of Discharge Summary of
Psychiatric Patient.” This is driven by the poor quality information sharing between hospital
and primary care team i.e. General practitioner which will compromise follow-up care after
discharge. Hence, there is need of a study which will provide an idea about expectation from
primary care team. I enclose a survey that will help me profile quality contents of discharge
summary.
I would be most grateful if you could oblige me by completing this survey, and then return it
to me in the enclosed envelope. If you could return it to me by the (01/06/2016) it would
allow me time to analyse the results before my thesis submission due date. I have obtained
ethics approval from Trinity College Ethics committee. An information sheet is enclosed for
your perusal. If you require any further information or clarification, please do not hesitate to
ring me on the above number.
Thank you for your assistance
Yours sincerely
Anil Kumar Deo
81
Appendix 8
Survey Questionnaire
Questionnaire for General Practitioner
Please find the survey questionnaire for developing a minimum data set for psychiatric
discharge summary. “Each question is optional. Feel free to omit a response to any
question; however the researcher would be grateful if all questions are responded to.”
A. Demographic details:
Item for
discharge
Summary
Do you think this
information should
to be included in
the discharge
summary? Please
tick
If you agree, please
indicate the priority
for this item
Additional Comment
1. Name Agree
Disagree
Mandatory
Optional
Conditional
2. Address Agree
Disagree
Mandatory
Optional
Conditional
3. Date of Birth Agree
Disagree
Mandatory
Optional
Conditional
4. Health Identifier Agree
Disagree
Mandatory
Optional
Conditional
5. Discharge
Destination
Agree
Disagree
Mandatory
Optional
82
address Conditional
6. Length of stay
in current
address
Agree
Disagree
Mandatory
Optional
Conditional
7. Nationality Agree
Disagree
Mandatory
Optional
Conditional
8. Next of Kin Agree
Disagree
Mandatory
Optional
Conditional
With regard to section (A) demographic Details, do you suggest any item that should be
excluded or additional information that should be included?
83
Appendix 8 (contd.)
“Each question is optional. Feel free to omit a response to any question; however the
researcher would be grateful if all questions are responded to.”
B. Primary Healthcare Professionals Details
Item for
discharge
Summary
Do you think this
information should
to be included in
the discharge
summary? Please
tick
If you agree, please
indicate the priority
for this item
Additional Comment
1. Name of general
practitioner
Agree
Disagree
Mandatory
Optional
Conditional
2. Address Agree
Disagree
Mandatory
Optional
Conditional
3. Phone Number Agree
Disagree
Mandatory
Optional
Conditional
4. E-mail Agree
Disagree
Mandatory
Optional
Conditional
5. Community care
service
Agree
Disagree
Mandatory
Optional
Conditional
6. G. P.
Identification
Number
Agree
Disagree
Mandatory
Optional
Conditional
84
Appendix 8 (contd.)
With regard to section (B) Primary Healthcare Professional, do you suggest any item that
should be excluded or additional information that should be included?
“Each question is optional. Feel free to omit a response to any
question; however the researcher would be grateful if all questions are responded to.
C. Admission and discharge details
Item for
discharge
Summary
Do you think this
information should to
be included in the
discharge summary?
Please tick
If you agree, please
indicate the priority for
this item
Additional
Comment
1. Date of
admission
Agree
Disagree
Mandatory
Optional
Conditional
2. Source of
referral
Agree
Disagree
Mandatory
Optional
Conditional
3. Method of
admission
Agree
Disagree
Mandatory
Optional
Conditional
4. Reason of
admission
Agree
Disagree
Mandatory
Optional
Conditional
5. Date of
discharge
Agree
Disagree
Mandatory
Optional
Conditional
85
6. Place discharge
to
Agree
Disagree
Mandatory
Optional
Conditional
7. Date of death Agree
Disagree
Mandatory
Optional
Conditional
8.
Post-mortem
flag
Agree
Disagree
Mandatory
Optional
Conditional
9. Treating
Consultant
Agree
Disagree
Mandatory
Optional
Conditional
With regard to section (c) Admission and discharge details, do you suggest any item that
should be excluded or additional information that should be included?
86
Appendix 8 (contd.)
“Each question is optional. Feel free to omit a response to any
question; however the researcher would be grateful if all questions are responded to.”
D. Clinical Information
S.N. Item for discharge
Summary
Do you think this
information should
to be included in the
discharge summary?
Please tick
If you agree, please
indicate the priority
for this item
Addition
al
Comme
nts
1. Presenting complaint Agree
Disagree
Mandatory
Optional
Conditional
2. Past Psychiatric History Agree
Disagree
Mandatory
Optional
Conditional
3. Family History Agree
Disagree
Mandatory
Optional
Conditional
4. Past Medical History Agree
Disagree
Mandatory
Optional
Conditional
5. Social History Agree
Disagree
Mandatory
Optional
Conditional
87
6. Occupational History Agree
Disagree
Mandatory
Optional
Conditional
7. Pre-morbid personality Agree
Disagree
Mandatory
Optional
Conditional
8.
Mental State Examination
Agree
Disagree
Mandatory
Optional
Conditional
9. Physical Examination Agree
Disagree
Mandatory
Optional
Conditional
10. Investigation Agree
Disagree
Mandatory
Optional
Conditional
11. ICD-10 diagnosis Agree
Disagree
Mandatory
Optional
Conditional
12. Progress and treatment
during admission
Agree
Disagree
Mandatory
Optional
Conditional
13. Place discharged to Agree
Disagree
Mandatory
Optional
Conditional
88
14. Discharge Medications Agree
Disagree
Mandatory
Optional
Conditional
15. Risk Factor Agree
Disagree
Mandatory
Optional
Conditional
16. Patient Follow-Up plan Agree
Disagree
Mandatory
Optional
Conditional
17. Advice to GP Agree
Disagree
Mandatory
Optional
Conditional
18. Number of Pages Agree
Disagree
Mandatory
Optional
Conditional
Appendix 8 (contd.)
With regard to section (d) Clinical Information, do you suggest any item that should be
excluded or additional information that should be included?
89
Appendix 9
Data Collection Tool for Reviewing Chart
DATA COLLECTION TOOL for reviewing chart
Date of Discharge Date of Dictation
Date of typed
Data Set Yes /No Data Set Yes/No
A. Patient Details (HIQA,
2013)
B. Primary Care Healthcare
Professional Details
1. Name (HIQA, 20130 Yes
No
1. Name of general
practitioner (HIQA,
2013)
Yes
No
2. Address(HIQA 2013) Yes
No
2. Address (HIQA,
2013)
Yes
No
3. Date of Birth (HIQA,
2013)
Yes
No
3. Phone Number Yes
No
4. Health Identifier(
HIQA 2013)
Yes
No
4. E-mail Yes
No
5. Discharge Destination
address (HIQA, 2013)
Yes
No
5. Community care
service
Yes
No
6. Length of stay in
current address
Yes
No
6. G.P. identification
No.
Yes
No
90
7. Nationality Yes
No
C. Admission and discharge details
8. Next of Kin Yes
No
1. Date of admission
(HIQA,2013)
Yes
No
D. Clinical Information 2. Source of referral(
HIQA, 2013)
Yes
No
1. Presenting complaint
(Jaco Serfontein et.al.
2011)
Yes
No
3. Method of
admission (HIQA,
2013)
Yes
No
2. Past Psychiatric
History(Jaco
Serfontein et.al. 2011)
Yes
No
4. Reason of
admission(Jaco
Serfontein et.al.
2011)
Yes
No
3. Family History( Jaco
Serfontein et.al. 2011)
Yes
No
5. Date of
discharge(HIQA,
2013)
Yes
No
4. Past Medical History(
Jaco Serfontein et.al.
2011)
Yes
No
6. Discharge
Method(HIQA
2013)
Yes
No
5. Social History (Jaco
Serfontein et.al. 2011)
Yes
No
7. Date of death
(HIQA, 2013)
Yes
No
6. Occupational
History(Jaco
Serfontein et.al. 2011)
Yes
No
8. Post-mortem
flag(HIQA, 2013)
Yes
No
7. Pre-morbid
personality(Jaco
Serfontein et.al. 2011)
Yes
No
9. Treating
Consultant(Jaco
Serfontein et.al.
2011)
Yes
No
91
8. Mental State (Jaco
Serfontein et.al.
2011)Examination
Yes
No
10. Legal Status Yes
No
9. Physical
Examination(Jaco
Serfontein et.al. 2011)
Yes
No
10. Investigation(Jaco
Serfontein et.al. 2011)
Yes
No
E. Future Management
11. ICD-10 diagnosis(Jaco
Serfontein et.al. 2011)
Yes
No
1. Hospital
Action(HIQA,
2013)
Yes
No
12. Progress and treatment
during admission(Jaco
Serfontein et.al. 2011)
Yes
No
2. GP’s Action( HIQA
2013)
Yes
No
13. Discharge
Medications(Jaco
Serfontein et.al. 2011)
Yes
No
3. Social Care Action
(HIQA, 2013)
Yes
No
14. Risk Factor(Jaco
Serfontein et.al. 2011)
Yes
No
4. Information Given
to patient and
carer(HIQA 2013)
Yes
No
F. Person completing discharge
summary details
5. Advice,
recommendation
and future plan
(HIQA, 2013)
Yes
No
1. Name( HIQA , 2013) Yes
No
6.
Number of
Pages(Jaco
Yes
No
92
Serfontein et.al.
2011)
2. Contact number(
HIQA , 2013)
Yes
No
7. Place discharged
to(Jaco Serfontein
et.al. 2011)
Yes
No
3. Job title( HIQA ,
2013)
Yes
No
4. Professional body
registration number(
HIQA , 2013)
Yes
No
8. Consultant sign off(
HIQA , 2013)
Yes
No
5. Signature( HIQA ,
2013)
Yes
No
9. Date of consultant
sign off( HIQA ,
2013)
Yes
No
6. Copy to( HIQA ,
2013)
Yes
No
10. Discharging
consultant Name(
HIQA , 2013)
Yes
No
7. Date of completion of
discharge summary(
HIQA , 2013)
Yes
No
11. Discharge
speciality( HIQA ,
2013)
Yes
No
12. Document
Reference number(
HIQA , 2013)
Yes
No
93
Appendix 10
Contents of Discharge Summary by HIQA (2013)
Patient Details
Primary Care Healthcare professional details.
94
Admission and Discharge details
Clinical Narrative
95
96
Future Management
Person Completing discharge summary
97
98